**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. After receiving the Resident's hospital discharge summary upon the resident's readmission to the facility, the facility failed to revise the resident's care plan to include the newly identified bowel problem. The facility's failure to ensure R7's Comprehensive Care Plan was revised as indicated has caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy was identified on 09/28/23 and was determined to exist on 08/04/23, in the area of 42 CFR §483.21 F657 Comprehensive Person-Centered Care Plans at the highest scope and severity (S/S) of J. The facility was notified of the Immediate Jeopardy on 09/28/23 at 10:15 AM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, and repeated falls. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. Review of R7's Care Plan Historical Copy, dated 06/29/23, provided by the facility revealed . [resident's name] has memory problems, impaired decision-making skills, and impaired ability to comprehend. Dx [diagnosis] dementia . [resident's name] needs assistance with daily ADL [activities of daily living] care .I need extensive [assistance] x1 [of one] person staff support with bed mobility . [resident's name] has potential for falls d/t [due to] dementia and limited mobility. Needs assistance with transfers and mobility. Hx [history] of falls. Poor safety awareness .Fall mats bilateral sides of bed .Fall mat with call light activation in place when resident in bed . The care plan did not include any interventions related to the resident using grab bars. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient found this am at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t scant amount of serous fluid present. VS [vital signs] 128/70, hr [hear rate] 74, 18 [respiration] temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position, patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of R7'sInterdisciplinary Note, dated 07/30/23 at 11:43 AM, revealed Case manager came to visit and assess patient after fall. Case manager requested for patient to be sent out for xrays and evaluation. Called 911 with nonemergency transport to [name of hospital] . Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room, CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER [emergency room] provider requested admission given rib fractures and risk for pneumonia .In the emergency room, CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm [centimeters] .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . Review of R7's Care Plan, initiated on 08/04/23 (resident's readmission), provided by the facility revealed .Falls. [R7's Name] has potential for falls d/t dementia and limited mobility. Needs assistance with transfers and mobility. Hx of falls. Poor safety awareness . Newly identified interventions included .room/bed rearranged .scoop air mattress .call light alerting fall mat to right side of bed . All of the newly identified interventions had a start date of 08/29/23, 25 days after R7 was readmitted to the facility; however, R7's Care Plan was not revised to include his entrapment. Additionally, R7's Care Plan was not revised to include the newly identified problem of constipation/impaction. During an interview on 09/27/23 at 2:16 PM, the Director of Nursing (DON) stated the MDS department would have been the ones responsible for updating R7's Care Plan after his readmission. The DON also stated the Care Plan directs the care that needs to be provided to the resident; however, the Care Plan was a resource and should be reviewed, but for what care the resident needed to receive, the nursing staff would go by the nursing 24-hour report. When asked if the resident's bowel problem should have been care planned, the DON stated she reviewed R7's hospital discharge summary; however, it was an oversight that the resident had an impaction. Had this issue been caught, it should have been added to R7's Care Plan. During an interview on 09/27/23 at 2:27 PM, the MDS Coordinator (MDSC) stated R7's Care Plan should have been revised prior to 08/29/23 since he was readmitted on [DATE]. The MDSC verified R7's Care Plan did not include any problem and/or interventions specifically related to his entrapment. The MDSC stated even though R7's bowel impaction was resolved while he was admitted to the hospital, this should have been included on his Care Plan upon readmission to the facility. The MDSC also stated she reviewed R7's Hospital Discharge Summary upon his readmission to the facility, but the impaction issue was an oversight. The MDSC further stated it was important R7's Care Plan would have been revised to ensure he received the appropriate plan of care. Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, revised October 2021, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, that are identified through evaluation and assessment, is developed and implemented for each resident .I. The comprehensive, person-centered care plan will: .8. Incorporate identified problem areas .N. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. O. The Interdisciplinary Team must review and update the care plan: 1. When there has been a significant change in the resident's condition; .3. When the resident has been readmitted to the community from a hospital stay . The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-657 continues at a scope and severity D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35. On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. R7's Physician's Orders were for R7 to have oxygen administered at two liters per minute (lpm) to keep his saturations above 90% for hypoxia (low level of oxygen). On 09/26/23, R7's oxygen concentrator was not working properly. The resident's oxygen saturation dropped to 83%. The facility determined that when the humidifier bottle was changed out, the cap was not correctly/fully applied and was not allowing oxygen to flow. Also, the Director of Nursing (DON) stated she assessed R7's oxygen saturation on 09/26/23; however, the DON did not document the assessment and did not document the incident in the resident's medical record. The facility also failed to have a system in place for bowel management to ensure nursing staff were monitoring residents' bowel movements. When R7 was transferred to the hospital for treatment related to the entrapment, it was discovered R7 had a fecal impaction which required an aggressive bowel regimen as treatment. Through record review a total of six residents (R4, R7, R8, R20, R21, and R22) were found not to have documentation of bowel movements. There was intermittent documentation that residents went at a minimum of 48 hours and up to five days without documentation of any bowel movements. The facility's failure to ensure acceptable professional standards of care has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/28/23 and determined to exist on 07/30/23 in the area of 42 CFR §483.21(b) Comprehensive Care Plans, (i) Meet professional standards of quality F658 at the highest scope and severity (S/S) of a L. The Administrator was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: 1. Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, repeated falls, pulmonary fibrosis, and sleep apnea. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. a. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient found this am at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t [due to] scant amount of serous fluid present. VS [vital signs] 128/70 [blood pressure], hr [heart rate] 74, [respirations] 18 temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position; patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of an untitled Communication Record document provided by the facility revealed the first time a physician was notified after R7's entrapment on 07/30/23 at 4:00 AM, was on 07/30/23 at 8:10 AM, four hours after the incident occurred. The documented communication read, [LPN11 or Registered Nurse (RN) 3] nurses with [facility name], state the patient [R7] has an abrasion on his hip, hit his right arm and chest. The patient is not complaining of pain . Continued review revealed a second communication on 07/30/23 at 8:30 AM, completed by the on-call physician read, .Reports pt [patient] was slumped over side of bed and accidentally rolled of (sic) this AM. He sustained some abrasions on his, R [right] arm, and chest. Denies there was any bleeding .Instructed to sent to ED [emergency department] if VS [vital signs] become unstable or patient begins to bleed uncontrollably. Will inform [R7's Attending Physician]. There was no documented evidence the nurse reported the details of the entrapment. Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room, CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER provider requested admission given rib fractures and risk for pneumonia . During an interview on 09/25/23 at 5:33 PM, RN3 stated he came on shift on 07/30/23 at approximately 5:45 AM. The RN stated he could not locate the nurse [LPN11] for the floor to do shift communication. RN3 stated he notified the nursing supervisor at 6:10 AM that he could not locate the nurse and needed shift report. Continued interview revealed after LPN11 was located and came to give him the shift report, she informed him that R7 had fallen and reported the resident had no substantial injuries, just some scratches and bruises on the ribs. RN3 stated being his first day out of orientation, he notified the nursing supervisor of the fall. RN3 further stated the day shift nursing supervisor and LPN11 entered into R7's room and he started medication pass. RN3 also stated he was later called to R7's room and told by R7's Care Connections Case Manager (CCCM) she wanted the resident sent to the hospital. She showed him the injuries and he was shocked because the resident had multiple injuries that were very visible. During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated during this interview with the surveyor was the first she had heard that R7 was wedged between the mattress and the grab bar on his bed. When listening to the nurses note dated 07/30/23 at 7:12 AM read to her by this surveyor, AP1 stated hearing the words wedged and bilateral legs under him was really distressing for her to hear. AP1 stated knowing those details, the resident should have been sent out to the emergency room sooner than he was. During an interview on 09/27/23 at 6:30 PM, LPN11 stated at approximately 4:00 AM on 07/30/23, CNA2 came to her medication cart and told her R7 was on the floor. Continued interview revealed LPN11 directly went to R7's room and discovered the right side of the resident's chest and his right arm were wedged in between the grab bar and his mattress. LPN11 stated R7's knees were barely touching the fall mat. LPN11 also stated R7 was wedged so tightly, the grab bar could not be lowered, there was no room to get a Hoyer lift, and the use of a gait belt would not have been safe. LPN11 stated she got a bedsheet and made a sling, slipped it under the resident, where she and the CNA got the resident unwedged and put him back into his bed. LPN11 further stated she had to push on the resident's mattress while pulling him to get him out of the grab bar. LPN11 stated her and RN4 later determined the resident's mattress edge failed by deflating and combined with R7's weight that was how he became wedged. LPN11 also stated by the time they got the resident back into bed, assessed, and started her paperwork, she did not see any serious injury, so she continued administering residents their medications and it did not seem emergent. The LPN stated no one ever followed up with her on the incident. Complete review of R7's Electronic Medical Record (EMR) revealed no documented evidence of an accurate assessment of R7's injuries as noted per the hospital discharge summary. b. Review of R7's Significant Change in Status MDS with an ARD of 08/16/23 revealed the facility assessed the resident as receiving oxygen therapy. Review of R7's current Physician Orders, located in the resident's EMR under order's tab revealed an order dated 08/04/23 of Oxygen at 2 liters/minute [per minute] to keep sats [saturations] above 90%. 2L [liters] inhalation every 12 hours for hypoxia . During an observation and interview on 09/25/23 at 1:56 PM, R7 was sitting at the dining room table with a peer. The resident was being administered supplemental oxygen via nasal canula. RN3 was asked to observe R7's oxygen concentrator and to verify how many liters per min was the resident's concentrator set at. RN3 stated the concentrator was set to 1.5 lpm. When asked who was responsible for setting the lpm on the concentrator, RN3 stated both nurses and CNAs were responsible for ensuring it was set correctly. During an observation and interview on 09/25/26 at 4:23 PM, R7 was lying in his bed, with his Continuous Positive Airway Pressure (CPAP/machine that keeps breathing airways open) on, being connected to his oxygen concentrator. RN3 who was present during the observation verified the concentrator was set to 1.5 lpm. RN3 stated during the observation, he realized the concentrator should have been set to 2 lpm and immediately corrected the concern. RN3 also stated it was important R7's oxygen be administered per his physician's order to ensure his oxygen saturation was maintained at 90% or greater. During an interview on 09/26/23 at 3:20 PM, R7's CCCM approached surveyor and stated at approximately 2:15 PM today, herself and a care connections nurse came to visit R7. The CCCM stated R7 was sitting in the common area in his wheelchair when the care connections nurse noticed R7's humidifier bottle was not bubbling like normal. The CCCM and care connection nurse assessed the nasal canula and they did not feel any air flowing, so they got a cup of water to put the nasal canula in and verified there was no oxygen flow. The CCCM stated they immediately took the resident's oxygen saturation, and it was 83%. At that point, the nurse was not visibly available, so she went to the Director of Nursing (DON's) office and reported the concern. The CCCM further stated the DON obtained a pulse oximeter from the nurse's station and checked R7's oxygen saturation and it was still at 83%. The CCCM stated the DON immediately obtained a portable oxygen tank and within a few minutes, the resident's saturations rose to 90%. The interview also revealed the resident was more confused than usual, could not form words, tired looking, and was moving his arms around slowly with no purpose. The CCCM stated the Administrator informed her that she determined the oxygen concentrator's humidifier bottle was the reason oxygen was not flowing. Specifically, the Administrator told her when the bottle was changed out, the cap did not puncture the bottle to allow for air flow. Observation on 09/27/23 at 4:37 PM revealed R7's oxygen concentrator was set at 2.5 lpm. During an interview on 09/28/23 at 11:27 AM, RN3 stated on 09/26/23 at around 2:30 PM, while at the nurse's station he learned that R7's oxygen saturation was in the 80s. RN3 also stated the DON explained to him that the resident was not receiving the oxygen because the cap of the humidifier bottle did not puncture the bottle like it should have when it was changed out. During an interview on 09/27/23 at 12:17 PM, the DON stated on 09/26/23, R7's oxygen was not being administered as ordered. The DON stated when she arrived to the floor the resident was confused more than normal. The DON also revealed she assessed R7's oxygen saturation and it was in the mid-80s; however, the DON stated she had not fully investigated the concern and did not know if she documented the assessment. Continued interview revealed she obtained a portable oxygen tank from the crash cart, and administered the oxygen to the resident and his saturations came back up. The DON stated she determined that whoever changed the humidifier bottle on the concentrator did not ensure when screwing the cap on the bottle that it punctured the bottle so oxygen could flow. When asked who was the staff person that changed the humidification bottle out, the DON stated she had not investigated that yet. The DON further stated it was a full bottle, so it had to have been changed recently. During an interview on 09/28/23 at 2:34 PM, AP1, who was R7's attending physician stated she was at the facility during the concern with R7's saturations being in the 80s on 09/26/23. AP1 stated she did not assess the resident but mentioned to the nurse that putting him in bed and applying his CPAP may be needed because the resident's carbon dioxide level may have built up. Continued interview revealed it was important R7's oxygen be administered as ordered to keep his saturation above 90%. AP1 stated she wanted his oxygen saturation 90% or above because if it is below 90% for a long period of time, the resident may not get enough oxygen to the organs of his body. c. Review of R7's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/01/23 through 06/03/23, 06/16/23 through 06/18/23, 06/22/23 through 06/24/23, 06/30/23 through 07/04/23, 07/26/23 through 07/30/23, 08/04/23 through 08/07/23, 08/17/23 through 08/21/23, 08/29/23 through 08/31/23, and 09/09/23 through 09/12/23. Review of R7's Hospitalists Discharge Summary, dated 08/04/23 revealed .In the emergency room, CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . 2.Review of R4's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. The surveyor requested R4's documentation of physician orders, daily bowel movement charting, and MARs; however, the facility never provided the requested documentation prior to leaving the building. 3. Review of R8's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/15/23 through 06/17/23, 07/29/23 through 08/01/23, 08/17/23 through 08/19/23, 08/25/23 through 08/29/23, and 08/31/23 through 09/04/23. 4. Review of R20's admission MDS with an ARD of 01/24/23 revealed the resident was admitted to the facility on [DATE]. Review of R20's quarterly MDS, with an ARD of 06/14/23, provided by the facility revealed the resident was readmitted to the facility on [DATE]. Review of R20's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 07/05/23 through 07/07/23, 07/14/23 through 07/16/23, 08/20/23 through 08/25/23, 08/30/23 through 09/01/23, 09/08/23 through 09/14/23, 09/18/23 through 09/20/23, and 09/22/23 through 09/24/23. During an interview on 09/27/23 at 11:45 AM, R20 stated he has gone up to five days without having a bowel movement. The resident stated he had only told the nurse one time because it was bothering him. R20 also stated the nurses or CNAs have not asked him about his bowel movements or he would have told them how many days he goes without a bowel movement. 5. Review of R21's admission MDS with an ARD of 10/27/22 revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, with an ARD of 07/21/23, provided by the facility, revealed the resident was readmitted to the facility on [DATE]. Review of R21's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/23/23 through 06/25/23, 07/10/23 through 07/12/23, 07/14/23 through 07/22/23, and 08/21/23 through 08/23/23. 6. Review of R22's undated Profile Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R22's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/24/23 through 06/26/23, 08/06/23 through 08/10/23, and 09/07/23 through 09/09/23. During an interview on 09/26/23 at 5:33 PM, RN3 stated he was not sure what the facility's protocol was; however, it was a nursing practice if a resident goes two consecutive days without having a bowel movement, then the nurse should notify the resident's physician. During an interview on 09/26/23 at 6:10 PM, the DON stated CNAs were to document each shift if their assigned residents had a bowel movement or not. When asked who was responsible for pulling the residents' bowel movement documentation, the DON stated there was no procedure in place directing what nurses or on what shifts the no bowel movement report was to be run. The DON also stated it was important the residents' bowel movements were tracked because going without a bowel movement for several days could cause multiple issues that could then lead to major health issues. The facility was asked for a policy related to professional standards and an untitled and undated facility letterhead document revealed This Facility uses the following: Lippincott Nursing Practice [Lippincott Manual of Nursing Practice]. The document did not reference an edition number nor any other information. Refer to F684, F689, and F695 The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-658 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure six of six residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for bowel movement monitoring received the necessary care and treatment in accordance with professional standards of practice. On 07/30/23, R7 was transferred to the hospital after becoming entrapped in between his mattress and grab bar. While receiving treatment, it was discovered that R7 had a fecal impaction. Record review revealed there were no documented bowel movements for R7 for five days leading up to the fecal impaction diagnosis. Additional record reviews revealed the facility's systemic failure of ensuring residents' bowel movements were monitored to prevent constipation. The facility's systemic failure has the potential to affect all residents who resided at the facility. The facility's failure to ensure residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/27/23 and was determined to exist on 07/30/23, in the area of §483.25 Quality of Care F684 at a scope and severity (S/S) of a L. The Administrator was notified of the Immediate Jeopardy on 09/27/23 at 4:55 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: 1. Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident to always be incontinent of bowels. Review of R7's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/01/23 through 06/03/23, 06/16/23 through 06/18/23, 06/22/23 through 06/24/23, 06/30/23 through 07/04/23, 07/26/23 through 07/30/23, 08/04/23 through 08/07/23, 08/17/23 through 08/21/23, 08/29/23 through 08/31/23, and 09/09/23 through 09/12/23. Review of R7's Medication [Administration] Record (MAR), dated June 2023 and provided by the facility revealed the resident's physician ordered the following bowel regimen medications to prevent constipation, Miralax (laxative) 17 gram/dose oral powder .by mouth every day as needed for constipation. Milk of Magnesia (laxative) 400 mg/5mL [milligram/milliliter] or suspension .by mouth every day as needed for constipation if no BM [bowel movement] x 2 [for two] days; diagnosis/reason = Constipation . Dulcolax (laxative) 10mg rectal suppository .every day as needed for constipation if no bm x 3 days . and Fleet Enema 19 gram-7 gram/118 mL- 1 rectal every day as needed for constipation unrelieved by suppository; diagnosis/reason = constipation unrelieved by suppository . Review of R7's readmission Physician's Orders, dated 08/04/23, provided by the facility revealed R7 was ordered the following Milk of Magnesia 400mg/5mL oral suspension-2400mg/30ml by mouth every day as needed for constipation if no BM x 2 days ., Miralax 17 gram/dose oral powder- 17g [grams] by mouth everyday as needed for constipation, Dulcolax 10 mg rectal suppository- 10mg every day as needed for constipation if no bm x 3 days, and Fleet Enema 19 gram-7 gram/118 mL - 1 rectal every day as needed for constipation unrelieved by suppository. Review of R7's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed R7 was not administer any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. Review of R7's Hospitalists Discharge Summary, dated 08/04/23 revealed .In the emergency room, CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated when reviewing R7's bowel monitoring documentation for the last week of July 2023 where there were several days with no documented bowel movement, and just now finding out the resident was diagnosed with a fecal impaction at the hospital, this was very distressing to her. AP1 also stated the PRN (as needed) medications were ordered for the purpose of ensuring the resident did not become constipated. AP1 further stated the facility should have implemented the PRN medications that she had ordered for R7. During an interview on 09/26/23 at 5:33 PM, Registered Nurse (RN) 3 stated he was not sure what the facility's protocol was; however, it was a nursing practice if a resident goes two consecutive days without having a bowel movement, then the nurse should notify the resident's physician. RN3 stated if a resident was to go multiple days without having a bowel movement, it could cause issues such as a bowel obstruction, pain, constipation, or an impaction. RN3 stated impactions were usually extremely painful. When asked how he would know if a resident had not had a bowel movement in two or more days, RN3 stated he was not for sure, and the facility had never told him that he needed to be going back and looking at Certified Nurse Aids (CNAs) documentation. During an interview on 09/26/23 at 6:10 PM, the Director of Nursing (DON) stated CNAs were to document each shift if their assigned residents had a bowel movement or not. When asked who was responsible for pulling the residents' bowel movement documentation, the DON stated there was no procedure in place directing what nurses or on what shifts the no bowel movement report was to be run. The DON also stated it was important the residents' bowel movements were tracked because going without a bowel movement for several days could cause multiple issues that could then lead to major health issues. 2. Review of R4's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R4's quarterly MDS, with an ARD of 07/05/23, provided by the facility revealed the facility assessed the resident as always continent of bowels. The surveyor requested R4's documentation of physician orders, daily bowel movement charting, and MARs; however, the facility never provided the requested documentation prior to leaving the building. 3. Review of R8's Significant Change in Status MDS, with an ARD of 08/25/23 revealed the resident was admitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R8 as being occasionally incontinent of bowels. Review of R8's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/15/23 through 06/17/23, 07/29/23 through 08/01/23, 08/17/23 through 08/19/23, 08/25/23 through 08/29/23, and 08/31/23 through 09/04/23. Review of R8's current Physician Orders, provided by the facility revealed the resident was ordered the following bowel regimen medications Dulcolax 5 mg tablet, delayed release - 10 mg rectal every day as needed for constipation and Fleet Enema 19 gram-7 gram/118 mL- 1 Rectal every day as needed for constipation. Review of R8's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed R8 was not administer any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. 4. Review of R20's admission MDS with an ARD of 01/24/23 revealed the resident was admitted to the facility on [DATE]. Review of R20's quarterly MDS, with an ARD of 06/14/23, provided by the facility revealed the resident was readmitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R20 as being frequently incontinent of bowels. Review of R20's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 07/05/23 through 07/07/23, 07/14/23 through 07/16/23, 08/20/23 through 08/25/23, 08/30/23 through 09/01/23, 09/08/23 through 09/14/23, 09/18/23 through 09/20/23, and 09/22/23 through 09/24/23. Review of R20's current Physician Orders, provided by the facility revealed the resident was ordered the following bowel regimen medications Dulcolax 5 mg tablet, delayed release - 10 mg rectal every day as needed for constipation and Fleet Enema 19 gram-7 gram/118 mL- 1 Rectal every day as needed for constipation. Review of R20's MAR, dated June 2023, provided by the facility revealed R20 was ordered the following bowel regimen medications, Colace Cap [capsule] 100MG CAPS-100 mg by mouth every 12 hours for constipation; diagnosis/reason = constipation, Milk of Magnesia -30ml as needed 30 ml daily as needed for constipation Continued review of the MAR revealed there was no documented evidence R20 was administered any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. R20's MARs for July 2023, August 2023, and September 2023 were requested; however, they were not received before the survey team exited the building and were not received after leaving the building. During an interview on 09/27/23 at 11:45 AM, R20 stated he has gone up to five days without having a bowel movement. The resident stated he has only told the nurse one time because it was bothering him. R20 also stated the nurses or CNAs have not asked him about his bowel movements or he would have told them how many days he goes without a bowel movement. 5. Review of R21's admission MDS with an ARD of 10/27/22 revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, with an ARD of 07/21/23, provided by the facility, revealed the resident was readmitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R21 as being always continent of bowels. Review of R21's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/23/23 through 06/25/23, 07/10/23 through 07/12/23, 07/14/23 through 07/22/23, and 08/21/23 through 08/23/23. Review of R21's MARs dated June 2023, July 2023, August 2023, and September 2023, provided by the facility, revealed R21 was ordered the following bowel regimen medications, Milk of Magnesia -30ml as needed 30 ml daily as needed for constipation, Dulcolax 10 mg rectal suppository every day as needed if no BM x3 days, for constipation and Fleet Enema 19 gram- 7 gram/118 mL- 1 rectal every day as needed if unrelieved [sic] by Dulcolax suppository for constipation. Continued review of the MARs revealed R21 was not administered any of the medications when he did not have a documented bowel movement within three days. 6. Review of R22's undated Profile Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R22's quarterly MDS, with an ARD of 06/29/23, revealed the facility assessed the resident as always being incontinent. Review of R22's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/24/23 through 06/26/23, 08/06/23 through 08/10/23, and 09/07/23 through 09/09/23. Review of R22's current Physician's Orders, provided by the facility revealed the resident was ordered the following bowel regiment medications, Dulcolax 10 mg rectal suppository- 10mg rectal every day as needed for constipation, Milk of Magnesia 400 mg/5 mL oral suspension give 30 mls-2400mg/30mls by mouth ever day as needed for constipation, polyethylene glycol POWD [powder] 17GM/SCOOP .every day as needed for constipation, and Fleet Enema 19 gram-7 gram/118mL- 1 rectal every day as needed for constipation. Review of R22's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed no documented evidence the resident was administered any of the as needed medications when there were not documented bowel movements for three or more days. During an interview on 09/27/23 at 3:38 PM, CNA 3 she would assume alert and oriented residents would tell her without her asking if they had a bowel movement. The CNA stated she checks on incontinent residents every two hours and would document in the computer if there was a bowel movement. CNA3 also stated if she did not get her charting completed by the end of her shift, she would inform the CNA for the next shift and the CNA would agree to chart for her. Continued interview with CNA3 revealed she rarely had time to chart bowel movement documentation because she was usually so busy answering call lights. Review of the facility's policy titled, Clinical Protocol: Bowel (Lower Intestinal Tract) Disorders, revised December 2017, revealed .Monitoring and Follow-Up .A. The associates and physician will monitor the individual's response to interventions and overall progress; for example .frequency and consistency of bowel movements . Review of the facility's undated Standing PRN Orders, document provided by the facility revealed, .Constipation: (always notify the provider of each additional step that is required) .If no BM for 48 hours, begin with: 1. Miralax 17GM PO [by mouth] QD [every day] + Colace 100mg PO Q12 [every 12 hours] .After 96 total hours since last BM: Choose from following options: 1. Magnesium hydroxide (MOM [milk of magnesium]) 400mg/5ml. Dose: 30 ml/day PO until BM, then D/C [discontinue] .Do not exceed more than 3 doses of the above medication. Please call provider . The survey team requested the facility provide the nursing practice the facility followed/referenced, specifically related to bowel management. The facility provided an untitled and undated facility letterhead document which read, This Facility uses the following: Lippincott Nursing Practice [Lippincott Manual of Nursing Practice]. The document did not reference an edition number nor any other information. The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-684 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents were free from accidents and hazards for one of three resident (Resident (R) 7) reviewed for accidents out of a sample of 35. On 07/30/23, R7 was discovered entrapped between his low air loss mattress and the grab bar attached to his bed. The resident sustained multiple fractures to his right and left ribs. Additionally, the facility failed to complete a timely and thorough investigation into the incident. An Immediate Jeopardy was identified on 09/26/23 and was determined to exist starting on 07/30/23, in §483.25(d) F689: Accidents. The Administrator was notified on 09/26/23 at 3:45 PM of the failure to prevent accidents and hazards for R7. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, and repeated falls. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. Review of R7's Care Plan Historical Copy, dated 06/29/23, provided by the facility revealed . [resident's name] has memory problems, impaired decision-making skills, and impaired ability to comprehend. Dx [diagnosis] dementia . [resident's name] needs assistance with daily ADL [activities of daily living] care .I need extensive [assistance] x1 [of one] person staff support with bed mobility . [resident's name] has potential for falls d/t [due to] dementia and limited mobility. Needs assistance with transfers and mobility. Hx [history] of falls. Poor safety awareness .Fall mats bilateral sides of bed .Fall mat with call light activation in place when resident in bed . The care plan did not include any interventions related to the resident using grab bars. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient [R7] found this am [morning] at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t [due to] scant amount of serous fluid present. VS [vital signs] 128/70, hr [hear rate] 74, 18 [respirations] temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position, patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of R7's Interdisciplinary Note dated 07/30/23 at 11:43 AM, completed by Registered Nurse (RN) 3 and provided by the facility revealed Case manager came to visit and assess patient after fall. Case manager requested for patient to be sent out for xrays and evaluation. Called 911 with nonemergency transport to [hospital name]. Supervisor notified. Review of the Incident Witness Statement Form, dated 07/30/23, completed by LPN11 and provided by the facility revealed .Patient [R7] was on edge of bed [with] bil knees on fall mat [sic]. his [sic] upper rt side was up against handrail. He was assessed, Alert [sic] and talking. Assisted back into bed with further assessment completed . Review of the Incident Witness Statement Form, dated 07/30/23, completed by CNA2 and provided by the facility revealed .upon on [sic] doing my final round I entered [R7's Name] room and he had slid out of his bed on the right side. I made sure he was breathing and notified the nurse [LPN11's Name] . Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room, CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER provider requested admission given rib fractures and risk for pneumonia . Review of the Safety Event Manager [facility incident report], with a completion date of 08/29/23, revealed .When did the event occur? 07/30/2023-04:00 [4:00 AM]. Who was the affected party? [R7's Name] .Was a physician or provider contacted in response to this event? Yes .07/30/2023- 07:30 [7:30 AM] .Briefly describe what happened. Patient found at side of bed on fall mat. How would you categorize this event? Falls & Slips .What was the cause of the fall? Accidental fall .Was any device, equipment, or software involved? No [inaccurate. Grab bar installed on the resident's bed]. What were the outcomes related to the event? No clinical outcome or consequences [Inaccurate. Resident sustained multiple rib fractures]. What was the severity of the event? Moderate: Event reached the person and caused moderate harm and required moderate intervention or care .Investigation Summary .resident transfers with pivot and x1 [times one] staff, w/c [wheelchair] for mobility. Resident was noted to have c/o [complaint of] pain and abrasions to his back/chest area on dayshift 7/30-resident sent out to ER [Emergency Room] per care manager's wishes-noted with L [Left] rib fractures 5-7 .In your opinion, what led to this event? resident [sic] attempted to get up unassisted/rolled out of the edge of bed. Give us your recommendations on what needs to be done as a result of this event. Scoop air mattress added, room rearranged with different bed placement, movement of the call alerting fall mat to the right side of the bed . The report was signed by the Administrator on 08/29/23 which indicated the investigation was completed 29 days after the incident occurred on 07/30/23. Additionally, the investigation did not include any information regarding the resident being entrapped in between the mattress and grab bar. Additionally, the Administrator's investigation did not include any information related to any abrasions around R7's neck as noted in the resident's hospital discharge summary. During an observation on 09/25/23 at 8:50 AM of R7's room, the resident's bed had a low air loss scoop mattress with bilateral grab bars. The left side of the bed was pushed all the way against the wall. During an observation and interview on 09/25/23 at 2:10 PM, Maintenance (MT) 1 measured the space/gap between R7's low air loss scoop mattress and the grab bar attached to the resident's right side of the bed. MT verified the gap was 4-5 inches and that was with him pressing some weight on the mattress. MT stated if the resident was to roll over to the edge of the low air loss scoop mattress, that would be the reason it would create a gap. MT also stated if the mattress was not a low air loss mattress, then there would be no gap created. Observation on 09/25/23 at 3:30 PM revealed R7 was lying in bed, rolled on his left side. During an interview on 09/25/23 at 4:45 PM, R7's Care Connections Case Manager (CCCM) stated she came into the facility to check on the resident after she received notification he [R7] had rolled out of bed. The CCCM stated R7 had abrasions around his neck, his chest and abdomen were bruised, and the resident had deep abrasions on his inner legs. During an interview on 09/25/23 at 5:33 PM, RN3 stated he came on shift on 07/30/23 at approximately 5:45 AM. RN3 stated he could not locate the nurse [LPN11] for the floor to do shift communication. RN3 stated he notified the nursing supervisor at 6:10 AM that he could not locate the nurse and needed shift report. Continued interview revealed after LPN11 was located and came to give him the shift report, she informed him that R7 had fallen and reported the resident had no substantial injuries, just some scratches and bruises on the ribs. RN3 stated being his first day out of orientation, he notified the nursing supervisor of the fall. RN3 further stated the day shift nursing supervisor and LPN11 entered into R7's room and he started medication pass. RN3 also stated he was later called to R7's room and told by R7's CCCM she wanted the resident sent to the hospital. She showed him the injuries and he was shocked because the resident had multiple injuries that were very visible. During an interview on 09/25/23 at 6:07 PM, when asked about resident's injuries and the nurse's note indicating he was wedged [entrapped], the Assistant Director of Nursing (ADON) stated she would not have thought that a grab bar would pose a risk. The ADON also stated this was a hazy area because the facility could not determine if R7 fell to the floor and then if attempting to get himself back up in the bed if that was when he became wedged or was it when he was attempting to get out of the bed. During an interview on 09/25/23 at 7:06 PM, RN4, who was the day shift nursing supervisor on 07/30/23 stated she was contacted by RN3 because he could not locate LPN11 to complete shift report. Continued interview with RN4 revealed when she received her shift report from the nightshift nursing supervisor, R7's fall was not reported. RN4 stated when she located LPN11, the LPN informed her that R7 had fallen during her shift but did not report include any details that the resident was wedged between the mattress and the grab bar. RN4 further stated she and LPN11 went to R7's room to lay eyes on him; however, she did not complete an assessment due to LPN11 informing her that she completed an assessment and treated minor abrasions. RN4 stated later that morning, she received a call from RN3 that R7's CCCM was demanding he be sent out because of the visible injuries. During an interview on 09/26/23 at 2:03 PM, the Administrator stated R7 was not assessed for the use of the grab bars. The Administrator also stated every resident bed at the facility had grab bars and they did not complete any assessments for any of the residents at the facility. The Administrator confirmed she did not complete a documented investigation until 08/29/23; however, she did not give a reason why it was not completed until then. During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated during this interview with the surveyor was the first she had heard that R7 was wedged between the mattress and the grab bar on his bed. When listening to the nurses note dated 07/30/23 at 7:12 AM read to her by this surveyor, AP1 stated hearing the words wedged and bilateral legs under him was really distressing for her to hear. AP1 stated knowing those details, the resident should have been sent out to the emergency room sooner than he was. During an interview on 09/27/23 at 3:44 PM, the Administrator stated all the mattresses in the facility were from Direct Supply and were a Panaca brand. The Administrator stated all the beds in the facility were Invacare C7 brand. Continued interview revealed the beds, and the mattresses were two different brands; however, they were compatible with one another. When asked if she was aware the manufacturer's manual for the Invacare C7 bed recommends to only use Invacare brand mattresses to prevent the risk of death or injury, the Administrator stated she was not aware of this. The Administrator also stated she was the person responsible for the purchasing of beds and mattresses. The Administrator stated she contacts the supplier, tells them what size mattresses and beds the facility needs, then the supplier makes the recommendation of what mattresses and beds would work together. During an interview on 09/27/23 at 6:30 PM, LPN11 stated at approximately 4:00 AM on 07/30/23, CNA2 came directly to her medication cart and told her R7 was on the floor. Continued interview revealed LPN11 directly went to R7's room and discovered the right side of the resident's chest and his right arm were wedged in between the grab bar and his mattress. LPN11 stated R7's knees were barely touching the fall mat. LPN11 also stated R7 was wedged so tightly, the grab bar could not be lowered, there was no room to get a Hoyer lift, and the use of a gait belt would not have been safe. LPN11 stated she got a bedsheet and made a sling, slipped it under the resident, where she and the CNA got the resident unwedged and put him back into his bed. LPN11 further stated she had to push on the resident's mattress while pulling him to get him out of the grab bar. LPN11 stated her and RN4 later determined the resident's mattress edge failed by deflating and combined with R7's weight that was how he became wedged. LPN11 also stated by the time they got the resident back into bed, assessed, and started her paperwork, she did not see any serious injury, so she continued administering residents their medications and it did not seem emergent. The LPN stated no one ever followed up with her on the incident. LPN11 also stated this was the scariest situation she had dealt with in her 33 years of nursing. Review of the Invacare bed user manual titled, Invacare [NAME] CS Series, revealed the user manual was for the CS7 bed model. Continued review of the manual revealed on page 19, DANGER! Risk of Death, Injury, or Adverse Health Consequences .Fall hazard exists due to use of Non-Invacare mattresses. Non-Invacare mattresses are potentially incompatible with Invacare beds. To avoid injury, ensure that only Invacare mattresses are used with Invacare beds at all times . Further review of the user manual revealed on page 18, DANGER! Risk of Death, Injury, or Damage. Patient entrapment from the use of bed side rails may cause injury or death. To Avoid patient entrapment: The Invacare mattress MUST fit firmly against the bed frame AND bedside rails to prevent patient entrapment. Follow the manufacturer's instructions .DANGER! Risk of Death, Injury, or Damage. Conditions such as .dementia, sleeping problems, and incontinence can significantly impact a patient's risk of entrapment .Monitor patients with these conditions frequently . Review of page 45 revealed .Bed Rails and Positioning Devices. DANGER! Risk of Death, Injury, or Damage. Patient entrapment from the use of bed side rails may cause injury or death. To avoid patient entrapment: The Invacare mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment .Periodically monitor gaps between the bed, mattress, and/or bed rail. Where gaps occur, patient entrapment is possible, and the mattress should be replaced. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of entrapment . Review of the facility's policy titled, Accidents and Incidents-Investigation and Reporting revised January 2020, revealed .Accidents or incidents involving residents shall be investigated and reporting completed, per state and federal requirements .A. The nurse should promptly initiate and document investigation of the accident or incident. B. The following information shall be included in the investigation, as applicable: 1. The date and time the accident or incident took place; 2. The nature of the injury; 3. The circumstances surrounding the accident or incident; 4. Where the accident took place; 5. The name(s) of witnesses and their accounts; 6. The resident's account of the incident; 7. The time the resident's Health Care Provider was notified, as well as the time the Healthcare Provider responded and his or her instructions; 8. The date/time the resident representative was notified and by whom . Review of the facility's policy titled, Falls, revised July 2023, revealed, .The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall .2. If a resident sustains a fall, or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated . The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-689 continues at a scope and severity D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's (DON) Job Descriptions, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. During an abbreviated survey, five Immediate Jeopardies were identified, with the highest scope and severity (S/S) of a L and four standard level tags were cited with the highest S/S being an F. The facility failed in the areas of 42 CFR 483.10 Notification of Change (F580), 42 CFR 483.12 Free from Misappropriation (F602), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657), 42 CFR 483.70 Resident Records-Identifiable Information (F842), 42 CFR 483.25 Bed Rails (F700), 42 CFR 483.25 Respiratory Care (F695), 42 CFR483.21 Comprehensive Care Plans/Services Meet Professional Standards of Quality (F658), and 42 CFR 483.25 Accidents (F689). The facility's failure to ensure it was administered in a manner that enables it to use its resources effectively and efficiently has caused or was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was identified on 09/28/23 at 42 CFR 483.70 Administration (F835) and was determined to exist on 07/30/23. The facility was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The Administrator was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of the Administrator's Job Description, effective 06/11/23, revealed Job Summary: Oversees the operational effectiveness of assigned facility. Responsibilities: Oversees the development and implementation of policies, procedures and strategies related to assigned facility. Ensures that facility is in compliance with federal, state, and local regulations. Monitors care delivery to determine changes that may be needed to improve outcomes and service standards. Reviews data to identify performance improvement opportunities. Develops, implements, and monitors operating budgets for areas of responsibility. Directs and coordinates activities of all medical, nursing, and administrative staff and services . Review of the DON's Job Description, effective date 07/10/22 revealed, Job Summary: Directs services, workflow and resources for assigned long-term care nursing area. Responsibilities. Develops departmental goals and objectives consistent with medical, administrative, legal, and ethical requirements of the long-term care health delivery system. Directs forecasting, planning, developing, organizing, implementing, directing, and evaluating all clinical services and programs to ensure high quality resident care. Plans, organizes, and directs all activities related to staffing, including hiring, orienting, evaluating, and continuing education initiatives. Prepares and monitors budget(s) and ensures that assigned nursing area operates within allocated funds. Coordinates and directs internal and externally-driven audits. Monitors admissions, discharges, and transfers to assure appropriate care and compliance with State and/or Federal regulations. Complexity of Work: Within scope of job, requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision . (Refer to F580, F602, F657, F658, F684, F689, F695, F700, F835, and F842) The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-835 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.